Talonavicular Uncoverage Angle Research Articles

Comparative Study between Arthroereisis and Corrective Osteotomies for the Management of Symptomatic Flexible Pes Planovalgus in Adolescents

Abstract pes planovalgus is a common foot deformity observed in adolescents which is characterized by a loss of the medial longitudinal arch and malalignment of the foot; hindfoot valgus and forefoot abduction which could progress with time causing pain that occur secondary to pressure medially over the prominent talar head. The treatment of this deformity should be directed to correct the foot malalignment, secure the stability of the foot during stance and correct the abnormal gait. The aim of the treatment is to obtain a foot with normal alignment which exhibits no pain and preventing the degenerative changes that may take place in the future. Surgical options should be offered to patients when conservative treatment failed. Numerous surgical procedures were described in pesplanovalgus correction that varies from bony osteotomies, subtalar extra-articular arthroeresis, intraarticular arthrodesis and triple arthrodesis accompanied with soft tissue procedures as indicated. When these are compared, all techniques have advantages and disadvantages. This study was conducted to evaluate the short term outcome of two methods of correction of pesplanovalgus; the extra-articular subtalar arthroereisis using subtalar sinus tarsi implant and bony corrective osteotomies in correction of flexible PPV in adolescents. Soft tissue procedures added to the operation if indicated mainly (gastroconemius recession and accessory navicular excision) Our study included 40 feet (25 patients) with pesplanovalgus. The patients divided into two groups 20 feet each. Group A underwent arthroereisis and group B underwent corrective osteotomies. The inclusion criteria were; Idiopathic flexible flatfoot deformity, symptomatic patients only and age between 10-14 years old. While the exclusion criteria were rigid flatfoot, flatfoot in adults (above 14 yrs old), severe talonavicular uncoverage angle (>40), neurogenic cases (cerebral palsy patient), patients with generalized ligamentous laxity. The outcome was assessed clinically by patient satisfaction, heel valgus angle, AOFAS hindfoot score and FAAM score. Radiologically the outcome was assessed by comparing the preoperative and postoperative measures of the lateral TCA, the AP and lateral talo-1st MTS angles, talonavicular coverage angle and the calcaneal pitch angle. Clinically the patient satisfaction was comparable in each of Group A were 17 patients (85.0%) were Satisfied; and 3 patients (15.0%) were unsatisfied compared to Group B were 18 patients (90.0%) were Satisfied and 2 patients (10.0%) were unsatisfied. Additionally, the two groups were comparable in heel valgus angle with the mean±SD in each of group A and group B was 2.75±2.62 compared to 2.05±2.01 respectively. Furthermore, the two groups were comparable in AOFAS score with the mean±SD in each of group A and group B was 89.25±8.34 compared to 91.25±8.97 respectively. As well as, the two groups were comparable in FAAM score with the mean & ±SD in each of group A and group B was 91.08±6.51, compared to 95.75±7.23 respectively. Radiologically; The two groups were comparable in lateral talus 1st met angle with the mean±SD in each of group A and group B was 3.45±3.06 compared to 2.02±2.08 respectively. Additionally, the two groups were comparable in lateral talocalc angle with the mean±SD in each of group A and group B was 32.65±5.05 compared to 30.50±5.62 respectively. Furthermore, the two groups were comparable in calc pitch angle with the mean±SD in each of group A and group B was 15.75±4.64 compared to 15.70±3.77 respectively. As well as, the two groups were comparable in AP talus 1st met angle with the mean±SD in each of group A and group B was 6.72±5.17 compared to 4.55±4.18 respectively. Also, the two groups were comparable in AP talonavicular coverage with the mean±SD in each of Group A and Group B was 6.95±4.77 compared to 4.10±3.30 respectively. There is no statistically significant difference between the group A and group B in all clinical and radiological measures. The extra-articular subtalar arthroereisis and bony corrective osteotomies in our study had been proved to be effective procedure for correction of flexible PPV feet in adolescents with comparable results.

Identification of the Apex of the Medial Longitudinal Arch Break in Progressive Collapsing Foot Disorder

Category: Midfoot/Forefoot Introduction/Purpose: Progressive Collapsing Foot Disorder (PCFD) is caused by failure of both dynamic and static structures. The aim of this study was to identify the anatomical location of the medial longitudinal arch break in symptomatic flat foot deformity and analyze its relationship with Meary's angle. Methods: We analyzed weight-bearing radiographs of 81 patients [mean age 53.7 years (range, 18-81) with 101 flat feet. The apex of the medial arch break was determined on the lateral foot radiographs as the intersection of the anatomical axis of the talus and the first metatarsal. Therefore, the overall centre of rotation of angulation (CORA) of the medial arch break was documented as the angle at its apex (Meary's angle). Each separate joint angulation was then calculated to determine if the overall CORA was made of separate CORAs. Correlations between the apex location, and the number of apices, with Meary's angle were conducted. Results: There was an isolated apex of deformity in 50.4% (51/101) of cases. These were localised at talonavicular joint (TNJ) in 47% (24/51), the naviculocuneiform joint (NCJ) in 52.9% (27/51) and none at the cuneiform-first metatarsal joint (C-1MTJ). The remaining 49.5% (50/101) had combination apices with the primary deformity being at TNJ in 58% (29/50), the NCJ in 40% (20/50), and 2% (1/50) at the C-1MTJ. The mean Meary's angle was -17.9° for isolated and -18° for combination which was not statistically significant (p=0.92). There was no statistical difference in the talonavicular uncoverage angle between the single and combination apices group (p= 0.99). Conclusion: The apex of the medial arch break occurs distal to the talonavicular joint in the majority of cases, and thereby the main insertion points of the posterior tibial tendon and spring ligament. In 52.9% (27/51) of cases, the deformity occurs solely distal to the TNJ and in 58% (29/50) cases, it involves joints in addition to the TNJ. These will involve pathology of other structures, including the naviculocuneiform ligament. Surgical strategies in successfully correcting Progressive Collapsing Foot Disorder will therefore need to address joints distal to the TNJ in the majority of cases.

Predictors of Deformity in Patients with Progressive Collapsing Foot Deformity and Valgus of the Ankle

Category:Hindfoot; Ankle; Ankle Arthritis; Midfoot/ForefootIntroduction/Purpose:Markers used for diagnosis and severity grading are well studied in patients with Progressive Collapsing Foot Deformity (PCFD). Medial facet subluxation (MFS) in weight-bearing computerized tomography (WBCT) has been established as an early indicator of peritalar subluxation (PTS). When the disease affects the ankle leading to a valgus talar tilt (class E), structures distal to this topography may behave differently, trying to compensate for proximal deformity. The aim of this study is to assess predictors of deformity in PCFD patients with and without valgus of the ankle. Our hypothesis is that MFS cannot be used in Class E patients as an accurate marker for the evaluation and staging of PCFD.Methods:In this IRB-approved retrospective case-control study, we analyzed WBCT imaging of 21 consecutive patients with PCFD with valgus of the ankle and 64 controls (flexible PCFD without ankle involvement). MFS (defined by the percentage of uncoverage), middle facet incongruence angle, middle cuneiform-to-floor distance, forefoot arch angle, talonavicular uncoverage angle, hindfoot moment arm (HMA), Foot and Ankle Offset (FAO), and talar tilt angle (TTA) were obtained and compared between groups using one-way ANOVA. A multivariate regression analysis was performed to evaluate which of the measurements influenced the alignment. A partition prediction model was constructed to assess how the variables contributed to the deformity. P values <0.05 indicated statistical significance.Results:Differences between groups were found for MFS, HMA, FAO, and TTA, with a lower mean value of MFS in PCFD patients with valgus of the ankle. An inverse relation between MFS and TTA was found, which was demonstrated by an increase in the talar tilt and a decrease in middle facet uncoverage. FAO values were affected by MFS in the control group (R2: 0.25) but not in the ankle valgus group (R2: 0.001), which was influenced mainly by the TTA (R2: 0.53). Additionally, a FAO value higher than 12.14 was found to be a strong predictor of deformity at the ankle.Conclusion:Medial facet subluxation was lower in patients with PCFD and valgus of the ankle (Class E), which demonstrates that MFS is a weak predictor of deformity severity. Therefore, this suggests that talar tilt angle and Foot and Ankle Offset should be used as disease markers in this group of patients. Furthermore, a FAO value above 12.14 may be an indicator of ankle involvement in PCFD patients.

The Plantar Fascia Talar Head Correlation: A Radiographic Parameter with a Distinct Threshold to Validate Flatfoot Deformity and Its Corrective Surgery on Conventional Weightbearing Radiographs

Category:Hindfoot; Midfoot/ForefootIntroduction/Purpose:Corrective surgery for flexible flatfoot deformity (FD) remains controversial, and one of the main reasons for this is the lack of standardised radiographic measurements to define an FD. Previously published radiographic parameters to differentiate between a specimen with and without FD do not have a commonly accepted and distinct threshold. Such a parameter would help validate FDs and the required corrective surgery. The purpose of this study was to assess a new conventional radiographic parameter with a distinct threshold that allowed the differentiation between feet with and without an FD and evaluate its application in corrective surgery for FD.Methods:The plantar fascia-talar head correlation (PTC) with its defined threshold was assessed by measuring the distance between the medial border of the plantar fascia [a connecting line between the medial border of the tibial sesamoid and the calcaneal insertion of the plantar fascia (mPCal)] and the centre of the talar head (DPT) on conventional dorsoplantar and lateral weightbearing radiographs; the authors were blinded to the clinical diagnosis of the 189 patients' first visits. Feet were grouped into specimens with and without an FD based on clinical examination. Then, the effect of surgical correction of FD on PTC was retrospectively evaluated on 38 patients. The intra-class correlation (ICC2) of the intra-observer reliability and the ICC2 of the inter-observer reliability of DPT measurement of 50 randomly selected specimens were calculated. The results of PTC were compared to the measurements of the lateral talar-1st metatarsal angle and the talonavicular uncoverage angle.Results:The intra-class correlation (ICC2) of the intra-observer reliability of DPT measurement was 0.95 (95%-confidence interval CI95[0.92, 0.97]), the ICC2 of the inter-observer reliability was 0.93 (CI95 [0.89, 0.95]). PTC, lateral talar first metatarsal angle and talonavicular uncoverage angle showed a statistically significant difference between the specimens with and without a FD (Wilcoxon test p-values <0.001). However, only the discriminatory power of PTC was distinct. The sensitivity and specificity of PTC was 0.88 (95%CI: 0.77-0.95) and specificity 0.96 (95%CI: 0.92-0.98), respectively, to identify an FD, consistent with the clinical examination. The identification of a sagittal plane FD caused by midfoot osteoarthritis on a lateral conventional weightbearing radiograph before measuring DPT increased the sensitivity for the combined method to 0.98 (95%CI: 0.9-1). Thirty-five of 38 surgeries successfully corrected the FD and PTC comparable to that in subjects without an FD. The unsuccessful corrections did not adequately correct the PTC.Conclusion:PTC is a unique and reliable radiographic parameter with an excellent threshold to confirm an FD, can be used intraoperatively to titrate the required amount for correction of FD under simulated weightbearing fluoroscopic imaging and is therefore useful to monitor and validate sufficient correction of its reconstructive surgery.PTC is an objective radiographic measurement to reliably describe the clinical subjective conclusion of any kind of FD with the exception FDs caused by an explicit midfoot pathology.

Predictors of Deformity in Patients with Progressive Collapsing Foot Deformity and Valgus of the Ankle

Category:Ankle; HindfootIntroduction/Purpose:Markers of diagnosis and severity are well studied in patients with Progressive Collapsing Foot Deformity (PCFD). Medial facet subluxation (MFS) in weight-bearing computerized tomography (WBCT) has been established as an indicator of peritalar subluxation and an earlier detector of the disease. When the disease affects the ankle leading to a valgus talar tilt (class E), structures distal to this topography may behavior differently, trying to compensate proximal deformity. The aim of this study is to assess predictors of deformity in PCFD patients with and without valgus of the ankle. Our hypothesis is that MFS could not be used in class E patients as an accurate value for estimation and staging of PCFD.Methods:In this IRB-approved retrospective case-control study we analyzed WBCT acquisitions of 21 consecutive patients with PCFD presenting valgus of the ankle and 64 controls (flexible PCFD with no ankle involvement). MFS (percentage of uncoverage), middle facet incongruence angle, middle cuneiform-to-floor distance, forefoot arch angle, talonavicular uncoverage angle, hindfoot moment arm (HMA), Foot and Ankle Offstet (FAO) and talar tilt angle (TTA) were obtained and compared between groups using oneway ANOVA. A multivariate regression analysis was performed to evaluate which of the measurements influenced the alignment. A partition prediction model was also constructed to find how the variables contributed to the deformity and its aspects. Statistical significancy was set in p values <0.05.Results:We found differences among groups only for MFS, HMA, FAO and TTA, with a lower mean value of MFS in patients with valgus of the ankle. An inverse relation between MFS and TTA was obtained in this group, demonstrated by increase in the talar tilt and decrease in middle facet uncoverage. MFS affected FAO values in the control group (R2: 0.25) but not in the ankle valgus group (R2: 0.001), being that this last one was influenced mainly by the TTA (R2: 0.53). A FAO value higher than 12.14 was found to be a strong predictor of deformity at the ankle.Conclusion:MFS was lower in patients with PCFD and valgus of the ankle, demonstrated as a weak predictor of deformity severity. In this group of patients (class E), talar tilt angle and Foot and Ankle Offset should be used as disease markers. A FAO value above 12.14 must be appreciated as a possible sign of ankle involvement in PCFD patients.

Talus morphology differs between flatfeet and controls, but its variety has no influence on extent of surgical deformity correction

BackgroundProgressive collapsing foot deformity (PCFD) is a complex 3-dimensional (3-D) deformity with varying degrees of hindfoot valgus, forefoot abduction, and midfoot varus. The first aim of this study was to perform a 3-D analysis of the talus morphology between symptomatic PCFD patients that underwent operative flatfoot correction and controls. The second aim was to investigate if there is an impact of individual talus morphology on the success of operative flatfoot correction.MethodsWe reviewed all patients that underwent lateral calcaneal lengthening for correction of PCFD between 2008 and 2018 at our clinic. Radiographic flatfoot parameters on preoperative and postoperative radiographs were assessed. Additionally, 3-D surface models of the tali were generated using computed tomography (CT) data. The talus morphology of 44 flatfeet was compared to 3-D models of 50 controls without foot or ankle pain of any kind.ResultsGroups were comparable regarding demographics. Talus morphology differed significantly between PCFD and controls in multiple aspects. There was a 2.6° increased plantar flexion (22.3° versus 26°; p = 0.02) and medial deviation (31.7° and 33.5°; p = 0.04) of the talar head in relation to the body in PCFD patients compared to controls. Moreover, PCFD were characterized by an increased valgus (difference of 4.6°; p = 0.01) alignment of the subtalar joint. Satisfactory correction was achieved in all cases, with an improvement of the talometatarsal-angle and the talonavicular uncoverage angle of 5.6° ± 9.7 (p = 0.02) and 9.9° ± 16.3 (p = 0.001), respectively. No statistically significant correlation was found between talus morphology and the correction achieved or loss of correction one year postoperatively.ConclusionThe different morphological features mentioned above might be contributing or risk factors for progression to PCFD. However, despite the variety of talar morphology, which is different compared to controls, the surgical outcome of calcaneal lengthening osteotomy was not affected.Level of evidenceIII.

Patient-Reported Outcomes and Radiographic Assessment in Primary and Revision Stage II, III, and IV Progressive Collapsing Foot Deformity Surgery.

Background:Progressive collapsing foot deformity (PCFD) is a progressive hindfoot and midfoot deformity causing pain and disability. Although operative treatment is stage dependent, few studies have looked at patient-reported and radiographic outcomes stratified by primary vs revision stage II, III, and IV reconstruction surgery. Our goal was to assess operative improvement using Patient-Reported Outcomes Measurement Information System (PROMIS) and to determine whether radiographic parameter improvement correlates with patient-reported outcomes.Methods:PROMIS Physical Function (PF) and Pain Interference (PI) scores were prospectively obtained on 46 consecutive patients who underwent PCFD reconstruction between November 2013 and January 2019. Thirty-six patients completed pre- and postoperative PROMIS surveys, 6 patients completed only preoperative PROMIS surveys, and 4 patients completed 12-month postoperative PROMIS surveys but did not complete preoperative PROMIS surveys. Minimum follow-up was 12 (average, 23) months. Radiographic correction was measured with pre- and postoperative weightbearing radiographs and correlated with PROMIS scores. Measurements included the talonavicular uncoverage angle, talonavicular uncoverage percentage, anteroposterior talo–first metatarsal angle, Meary angle, medial cuneiform height (MCH), and medial cuneiform–fifth metatarsal height.Results:For the overall cohort, PROMIS PF increased significantly from 37.5±5.6 to 42.3±7.1 (P = .0014). PROMIS PI improved significantly from 64.5±6.0 to 55.1±9.8 (P < .0001). Preoperative, postoperative, and change in PROMIS scores were not statistically different between PCFD stages. Change in PROMIS PI was significantly greater in primary (–12.3) vs revision (–3.7) surgery (P = .0157). Change in PROMIS PF was greater in primary (+6.0) vs revision surgery (+2.3) but did not reach statistical significance. All radiographic measurements improved significantly (P < .05). In primary stage II PCFD, postoperative PROMIS scores correlated with postoperative MCH (PF: r = 0.7725, P = .0020; PI: r = –0.5692, P = .0446).Conclusion:Patient-reported and radiographic outcomes improved significantly after PCFD reconstruction. We found no significant difference in preoperative, postoperative, or change in PROMIS scores between PCFD stages. However, stage III patients had smaller improvements in PROMIS PF, which we feel may be secondary to change in function after arthrodesis. Primary operations had better patient-reported outcomes compared to revision operations. In primary stage II PCFD, reconstructing the medial arch height correlated significantly with improvement in pain and functionality.Level of Evidence:Level II, prospective cohort study.

Correlation Between Three-Dimensional Biometric Weightbearing CT Assessment of Hindfoot Alignment and Conventional Measurements of Adult Acquired Flatfoot

Category:Hindfoot; Ankle; OtherIntroduction/Purpose:Semi-automatic three-dimensional (3D) biometric weightbearing CT (WBCT) tools have been shown to accurately demonstrate the relationship between the center of the ankle joint and the tripod of the foot. The measurement of the Foot and Ankle Offset (FAO) represents an optimized biomechanical assessment of foot alignment. The objective of this study was to evaluate the correlation between FAO and traditional adult acquired flatfoot deformity (AAFD) markers, measured in different planes. We hypothesized that the FAO would significantly correlate with other radiographic markers of pronounced AAFD.Methods:In this retrospective comparative study, we included 113 patients with stage II AAFD, 43 men and 70 women, mean age of 53.5 (range, 20 to 86) years. Three-dimensional coordinates (X, Y and Z planes) of the foot tripod (most plantar voxel of the first and fifth metatarsal heads, and calcaneal tuberosity) and the center of the ankle joint (most proximal and central voxel of the talar dome) were harvested by two blinded and independent fellowship-trained orthopedic foot and ankle surgeons. The FAO was automatically calculated using the 3D coordinates by dedicated software. Multiple WBCT parameters related to the severity of the deformity in the coronal, sagittal, and transverse plane were manually measured.Results:We found overall good to excellent intra (range, 0.84-0.99) and interobserver reliability (range, 0.71-0.96) for manual AAFD measurements. FAO semi-automatic measurements demonstrated excellent intra (0.99) and interobserver reliabilities (0.98). Hindfoot moment arm (p<0.00001), subtalar horizontal angle (p<0.00001), talonavicular uncoverage angle (p=0.00004) and forefoot arch angle (p=0.0001) were the only variables found to significantly influence and correlate with FAO measurements, with an R-squared value of 0.79. A value of hindfoot moment arm of 19.8mm was found to be a strong threshold predictor of increased values of FAO, with mean values of FAO of 6.5 when the HMA was lower than 19.8mm and 14.6 when the HMA was equal or higher than 19.8mm.Conclusion:We found that 3D WBCT semi-automatic measurements of Foot and Ankle Offset (FAO) significantly correlated with traditional markers of pronounced AAFD. HMA, subtalar horizontal angle, talonavicular uncoverage angle and forefoot arch angle were found to explain 79% of the variations in FAO measurements. FAO Measurements were also found to be more reliable than the manual measurements. The FAO offers a more complete biomechanical and multiplanar assessment of the AAFD, that that accounts for relative positioning of the foot tripod and the center of the ankle joint, representing in a single measurement the three-dimensional components of the deformity.

The Influence of Preoperative Deformity Severity in Postoperative Patient Reported Outcomes in Adult Acquired Flatfoot

Category:Ankle; Hindfoot; OtherIntroduction/Purpose:Adult acquired flatfoot deformity (AAFD) is a complex deformity. Previous work has demonstrated correlation between postoperative foot alignment and patient-reported outcomes. While this work has provided essential targets for surgeons performing flatfoot reconstruction, there is an absence of data that would enable surgeons to predict which patients are likely to have greater or less improvement after surgery based on their preoperative deformity. Conventional radiographs alone may not provide enough detail to isolate individual elements of the deformity. Weightbearing CT (WBCT) allows for far more precise analysis in this regard. We hypothesized that there would be a set of parameters defining preoperative alignment on WBCT that would predict which patients are at risk for a lower magnitude of postoperative improvement in patient-reported outcomes (PROs).Methods:In this retrospective IRB-approved study, patients that underwent surgical flatfoot reconstruction after having a preoperative standing WBCT were identified. Preoperative WBCT images were evaluated by two independent/blinded observers. Multiple parameters related to preoperative alignment and AAFD severity were measured in the sagittal, coronal and transverse planes. Parameters measured included talus-first metatarsal angle; distances between the floor and the navicular, medial cuneiform and cuboid; subtalar joint horizontal angle; superior talar - inferior talar angle; subtalar joint subluxation; talonavicular uncoverage angle; hindfoot moment arm (HMA); and foot and ankle offset (FAO). Prospectively collected data regarding preoperative and postoperative PROs was evaluated. Six PROs components were assessed: physical function; pain interference, pain intensity, global mental health, global physical health and depression. Multivariate regression analysis and a partition prediction model were used to assess the correlation between preoperative alignment and improvement in PROs. P-values of less than 0.05 were considered significant.Results:A total of 51 patients with a preoperative WBCT and postoperative PROs scores were identified and included. Demographic data is shown in Table 1. Multivariate regression analysis demonstrated that preoperative alignment significantly correlated with improvement in three out six components of PROs: pain interference, pain intensity and global mental health. The strongest predictor of improvement in PROMIS physical function t-score was medial cuneiform to floor distance, for pain interference t-score: cuboid to floor distance, for pain intensity: subtalar joint subluxation, for depression t-score: superior talar - inferior talar angle, and for global physical and mental health t-scores: sagittal talus-first metatarsal angle.Conclusion:Our analysis yielded readily identifiable cutoffs for WBCT measurements, where values above or below were correlated with significant differences in the magnitude of PRO score change. Interestingly, measures of sagittal plane collapse and hindfoot valgus were the most predictive of score changes. This data provides useful information for surgeons counseling patients prior to flatfoot reconstruction. Future work using this data to develop prediction models for postoperative outcomes would be valuable, as would studies using WBCT to evaluate the relationship between postoperative corrected alignment and PROs.Complete results are shown in the attached Table.

Outcomes after Tibiocalcaneonavicular Ligament Reconstruction in Stage IIB and Stage IV Adult Acquired Flatfoot Deformity

Category:Hindfoot; Ankle; Midfoot/ForefootIntroduction/Purpose:The tibiocalcaneonavicular ligament (TCNL) is formed from the confluence of the superficial deltoid ligament and the superomedial spring ligament. In advanced flexible adult acquired flatfoot deformity (AAFD), progressive strain on the TCNL can lead to spring ligament tears, deltoid insufficiency, and eventual medial peritalar instability. Historically, medial peritalar instability was corrected using calcaneal osteotomy in conjunction with isolated spring or deltoid reconstruction. A recent study (Brodell et al.) demonstrated the efficacy of TCNL reconstruction in patients with medial peritalar instability. The purpose of this study is to add to this literature using patient-reported and radiographic outcomes in patients undergoing TCNL reconstruction. Patient-reported outcomes were collected using Patient Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) surveys.Methods:Sixteen patients (mean age 50.25 years; 11 female, 5 male) who underwent TCNL reconstruction were prospectively identified. TCNL reconstruction was indicated for stage IIB patients (n=13) with large spring ligament tears (>1.5cm on MRI or intraoperatively) or if osseous correction did not provide adequate talonavicular joint correction. TCNL reconstruction was indicated in stage IV patients (n=3) if deltoid reconstruction required additional medial stabilization. No patients underwent lateral column lengthening osteotomies. PROMIS scores were obtained at baseline and at minimum 12-months follow-up (average 16 months). Surgical success was determined using minimum clinically important differences (MCID), defined as improvement greater than one-half the standard deviation of each pre-operative PROMIS domain (PF: +2.9 and PI: -2.5). Pre- and post-operative radiographic parameters were measured: talonavicular uncoverage angle, talonavicular uncoverage percentage, AP talo-first metatarsal angle, Meary’s angle, and medial cuneiform height (MCH). Correlation coefficients determined the relationship between radiographic parameters and PROMIS scores.Results:PROMIS PF scores improved significantly from 38.1+-5.8 to 44.1+-7.1 (p=0.0087). PROMIS PI scores improved significantly from 62.9+-5.1 to 52.3+-8.9 (p=0.0025). Seventy-nine and 77 percent of patients had successful surgeries, as defined by MCIDs in the PROMIS PF and PI domains, respectively. Talonavicular uncoverage percentage and Meary’s angle improved significantly from 34.4+-13.4 to 26.3+-9.9 percent (p=0.0360) and 19.2+-8.8 to 15.3+-6.2 degrees (p=0.0089), respectively. Talonavicular uncoverage angle improved from 29.3+-9.6 to 23.3+-8.0 degrees (p=0.0562), AP talo-first metatarsal angle improved from 15.2+-10.2 to 10.4+-9.0 degrees (p=0.0555), and MCH improved from 13.5+-6.2 to 15.9+-4.8 millimeters (p=0.1374). Post- operative MCH correlated significantly with post-operative PROMIS PF scores (r=0.5941; p=0.0152). Change in AP talo-first metatarsal angle correlated significantly with change in PROMIS PI scores (r=0.5682; p=0.0427). No other correlations were significant.Conclusion:Patients with stage IIB and stage IV AAFD who undergo TCNL reconstructions have excellent patient-reported and radiographic outcomes. Reconstruction of the medial longitudinal arch, as measured by post-operative MCH, is associated with higher post-operative functionality. Surgical correction of midfoot abduction, as measured by change in the AP talo-first metatarsal angle after surgery, is associated with improvements in pain. In patients with medial peritalar instability, TCNL reconstruction can be a valuable technique to correct the sagittal arch, prevent excessive midfoot abduction, and improve pain and functionality.

Radiographic Outcomes in the Treatment of Type II Adult Acquired Flatfoot Deformity Following Lateral Column Lengthening with a Titanium Wedge versus Autograft or Allograft

Category:Midfoot/ForefootIntroduction/Purpose:Lateral column lengthening (LCL) is a surgical procedure used to manage forefoot abduction occurring in patients with stage IIB Adult Acquired Flat Foot Deformity (AAFD). This procedure utilizes an opening wedge osteotomy of the calcaneus which is then filled with autograft, allograft, or a titanium wedge. The primary aim of this study was to compare the radiographic outcomes of these different bone substitutes in the setting of stage IIB AAFD with the use of LCL.Methods:All patients who underwent LCL from October 2008 until October 2018 were retrospectively reviewed. Preoperative weight bearing radiographs, initial postoperative radiographs and 1-year weight bearing radiographs were reviewed. The following radiographic measurements were recorded: talonavicular uncoverage angle, incongruency angle, and calcaneal pitch.Results:A total of 44 patients were included in our study. The mean age of the cohort was 54 (range 18-74). The study cohort was divided into two groups. There were 17 (38.7%) patients that received a titanium wedge and 27 (61.5%) that received autograft or allograft. Patients that underwent LCL with the autograft/allograft group were significantly older (p=0.006). Patients who underwent LCL with a titanium wedge had a significantly higher preoperative talonavicular angle (p=0.013). There were no significant differences in post-operative talonavicular uncoverage angle, incongruency angle or calcaneal pitch at 6 months or 1 year.Conclusion:Adult acquired flat foot deformity is a difficult disorder to treat surgically. Lateral column lengthening is a common surgical procedure used to treat forefoot abduction that occurs. Our results show that at 6 months and 1 year no radiographic difference exists between autograft/allograft bone substitutes versus titanium wedge in LCL. Future research should evaluate the differences in patient reported outcomes between autograft/allograft versus titanium wedge bone substitutes.

Patient-Reported and Radiographic Outcomes in Primary and Revision Stage II, III, and IV Adult- Acquired Flatfoot Deformity Surgery

Category:Hindfoot; Midfoot/ForefootIntroduction/Purpose:Adult-Acquired Flatfoot Deformity (AAFD) is a progressive hindfoot and midfoot deformity that causes pain and disability. It presents as a plano-valgus deformity from the failure of static and dynamic medial osteoligamentous stabilizers. Stage II presents as a passively correctable, flexible deformity of the foot; stage III presents as a fixed or arthritic deformity of the foot; and stage IV presents with marked deformity of the foot caused by failure of the deltoid ligament and subsequent peritalar instability. Although operative treatment of AAFD is dependent on the stage, there is little data on patient- reported and radiographic outcomes stratified by primary versus revision stage II, III, and IV reconstruction surgery.Methods:Patient Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) scores were prospectively obtained on 46 consecutive patients who underwent AAFD reconstruction between November 2013 and January 2019 with minimum 12-month follow-up (average 23 months). Twenty patients underwent stage II reconstruction, 5 of which were revision surgeries; 19 patients underwent stage III reconstruction, 8 of which were revision surgeries; and 7 patients underwent stage IV reconstruction, all of which were primary surgeries. Radiographic correction was measured pre- and post-operatively and correlated with PROMIS scores. Measurements included the talonavicular uncoverage angle, talonavicular uncoverage percent, AP talo-first metatarsal angle, Meary’s angle, medial cuneiform height, and medial cuneiform-fifth metatarsal height.Results:For the overall cohort, PROMIS PF increased significantly from 37.6+-5.7 to 42.4+-6.8 (p=0.0014). PROMIS PI improved significantly from 64.7+-6.3 to 54.6+-9.5 (p<0.0001). PROMIS scores were not statistically different between AAFD stages. Change in PROMIS PI was significantly greater in primary (-12.3) versus revision (-3.7) surgery (p=0.0157). Change in PROMIS PF was non- significantly greater in primary (+4.0) versus revision surgery (+2.3). All radiographic measurements improved significantly (p<0.05). In primary stage II AAFD, pre-operative PROMIS PI scores correlated with pre-operative medial cuneiform-fifth metatarsal height (r = -0.606, p = 0.0479). In addition, in primary stage II AAFD, post-operative PROMIS scores correlated with post-operative medial cuneiform height (PROMIS PF: r=0.7725, p=0.0020; PROMIS PI: r=-0.5692, p=0.0446).Conclusion:Patient-reported and radiographic outcomes improve significantly after AAFD reconstruction. There was no significant difference in PROMIS scores between AAFD stages. However, stage III patients had non-significantly lower improvements in PROMIS PF, likely due to loss of function after arthrodesis. Primary operations had better patient-reported outcomes compared to revision operations. In primary stage II AAFD, reconstructing the medial arch correlates significantly with improvement in pain and functionality. This survey of outcomes after primary and revision stage II, III, and IV reconstruction should help clinical decision making by providing data on expected surgical improvement.

Radiographic Outcomes after Flexible Flatfoot Reconstruction with and without Spring Ligament Reconstruction

Category:HindfootIntroduction/Purpose:The purpose of this study was to determine postoperative radiographic differences between patients who underwent flexible flatfoot reconstruction and spring ligament repair with a FiberTape suture device versus those who underwent spring ligament reconstruction with suture repair alone or those without reconstruction of the spring ligament for patients with Stage II adult acquired flatfoot deformity (AAFD).Methods:84 patients with Stage II AAFD met inclusion criteria with 18 undergoing flatfoot reconstruction and spring ligament (SL) repair with a FiberTape suture device (SL+FT), 12 with suture repair alone (SL+suture), and 54 without repair of the SL. Radiographic measurements were made on weight bearing radiographs pre- and postoperatively at an average of 90 ±108 weeks after surgery. The radiographic measurements included tibiotalar tilt (TT), talar-first metatarsal angle (T1M), talar-second metatarsal angle (T2M), talonavicular uncoverage angle (TN), Meary’s angle (MA), calcaneal pitch (CP), medial column height (MCH), and lateral column height (LCH). Statistical analysis was performed using two-way ANOVA.Results:There were no differences in preoperative radiographic measurements between the three groups. Postoperatively, the SL+FT and SL+suture groups had statistically significantly improved radiographic outcomes for T1M, T2M, TN, MA, CP, and LCH when compared to the no SL repair group (p<0.05). There were no differences in any radiographic outcomes between the SL+FT and SL+suture groups (Figure 1).Conclusion:Spring ligament reconstruction with either a FiberTape construct or suture repair alone demonstrates significant improvements in postoperative radiographic outcomes after undergoing flexible flatfoot reconstruction at an average of 2 years after surgery as compared to patients that did not have SL repair. The results of our study support spring ligament repair or reconstruction for patients when performing flexible flatfoot surgery for Stage II AAFD.

Weightbearing CT and MRI findings of Stage II Flatfoot Deformity: Can We Predict Patients at High- Risk for Foot Collapse?

Category:HindfootIntroduction/Purpose:Adult acquired flatfoot deformity (AAFD) is characterized by concurrent bony deformities, tendinous and ligamentous insufficiencies. Weightbearing CT (WBCT) allows excellent dynamic evaluation of the relative three-dimensional positioning of the tarsal bones. MRI provides accurate evaluation of soft tissue integrity in the unloaded foot. Study’s objective was to evaluate the correlation between bone deformity and soft tissue insufficiency in patients with stage II AAFD, using WBCT and MR images. We hypothesized that significant correlation would be found between WBCT measurements of increased longitudinal arch collapse, hindfoot valgus, peritalar subluxation and forefoot abduction, with MRI findings demonstrating degree of soft tissue involvement.Methods:This retrospective comparative study included 55 patients (56 feet) with stage II AAFD, 20 men and 35 women, mean age of 52.5 (range, 20 to 78) years. Multiple WBCT and MRI variables related to the severity of the deformity were evaluated by four blinded and independent readers (two radiologists and two foot and ankle surgeons), including: arch collapse (navicular-floor distance and forefoot arch angle), hindfoot alignment angle (HAA), forefoot abduction (talonavicular uncoverage angle), subtalar joint subluxation, sinus tarsi and subfibular impingement, and soft tissue insufficiency (posterior tibial tendon, spring and talocalcaneal ligaments). Tendinous and ligamentous involvement on MRI were graded from zero (normal) to four (complete tear). Intra- and interobserver reliabilities were assessed by Pearson/Spearman’s and intraclass correlation coefficient, respectively. A multiple regression analysis was used to evaluate the relationship between bone alignment (WBCT variables) and soft tissue injury (MRI variables). P-values of less than 0.05 were considered significant.Results:We found overall good to excellent intra (range, 0.83-0.99) and interobserver reliability (range, 0.71-0.97) for WBCT measurements and MRI readings. Spring ligament superomedial component involvement was the only finding to correlate with medial column collapse and decreased navicular-floor distance (p=0.03). Superomedial spring ligament and PTT degeneration were also significantly correlated with increased HAA (p<0.01). Involvement of the talocalcaneal interosseous ligament significantly correlated with increased forefoot abduction as measured by the talonavicular uncoverage angle. Spring ligament degeneration, of both superomedial and inferior components, and talocalcaneal interosseous ligaments significantly correlated to subtalar joint subluxation (p<0.001). Involvement of the talocalcaneal interosseous ligament was the only one to significantly correlate to the presence of subfibular impingement (p=0.02). Degeneration of the PTT was significantly associated with sinus tarsi impingement (p=0.04).Conclusion:This study is the first to evaluate correlation between bone, tendinous and ligamentous involvement in AAFD patients, using WBCT and MR images. Our results demonstrated that progressive bone deformity in WBCT is significantly correlated to MRI involvement of the PTT and other important restraints such as the spring and talocalcaneal ligaments. The implications are that WBCT can predict ligamentous injuries and that MRI can predict dynamic bone deformity in AAFD patients. Furthermore, the correlation of bone and soft tissue involvement could impact surgical planning of flatfoot patients, decreasing thresholds for additional soft tissue procedures such as a spring ligament reconstruction.

Early Outcomes of Pes Planus Reconstruction Using Either Hamstring Allograft or Synthetic Ligament

Category:Hindfoot, Midfoot/ForefootIntroduction/Purpose:Maintenance of the medial longitudinal arch is crucial to efficient kinematics in gait. It is supported by as complex interplay of osseous structures, ligaments, extrinsic tendons and plantar fascia.Two ligaments critical to stabilising the medial longitudinal arch are the Spring (Calcaneofibular) and Naviculocuneiform ligaments. The Spring Ligament serves as a sling within the “Acetabulum Pedis” to orientate the Talus relative to the Calcaneus and Navicular. The Naviculocuneiform ligament is an important plantar tension band and a separate entity to the Posterior Tibial Tendon (PTT) insertion. Attenuation of these ligaments leads to Pes Planus deformity and subsequent defunctioning of the PTT. This study evaluates the functional and radiological outcomes of Spring and Naviculocuneiform ligament reconstruction using Hamstring (Semitendinosis) Allograft and Synthetic ligament (Internal BraceTM, Arthrex).Methods:33 consecutive Pes Planus reconstructions were performed between 11/11/2013 and 06/03/2018. All patients were followed up prospectively with serial radiographs and functional scores including; MOXFQ, EQF5D and VAS. Minimum follow up was six months.At the midpoint during the study there was transition to using Synthetic Ligament instead of allograft. This was due to availability and ease of use.Surgical technique for both reconstructions included a proximal medial gastrocnemius recession and medialising calcaneal osteotomy. For allograft reconstructions, a pre-tensioned Semitendinosis allograft was fixed proximally to Talar neck using a tenodesis screw and passed plantar to PTT and through a bone tunnel in the medial cuneiform. Synthetic ligaments were inserted from the Sustentaculum Tali to the medial cuneiform in a hammock fashion. In both reconstructions tendinopathic PTTs were excised and a Flexor Digitorum Longus transfer used.Results:There were 17 synthetic ligament reconstructions (6 male, 11 female) and 16 allograft reconstructions (6 male, 10 female). Groups were matched pre-operatively for age, functional scores and radiological markers (T test P values >0.05).At six months significantly better improvements were observed in the synthetic ligament group compared to allograft group with regards to VAS, MOXFQ pain score, Meary’s line, 1st metatarsal Talus angle, Talonavicular uncoverage angle and Hindfoot alignment (T test P < 0.05).Statistical significance was maintained at 12 months with the synthetic ligament providing a significantly better reduction of Meary’s line 1st Metatarsal Talar angle, Talonavicular uncoverage and hindfoot alignment. 2 patients were revised to double fusions in the allograft group and 1 patient revised in the synthetic ligament group.Conclusion:Statistically significant improved functional scores and radiological appearance can be found up to 1 year following Synthetic ligament reconstruction of the Spring and Naviculocuneiform ligaments when compared to Hamstring allograft.

The Role of the Anterior Talofibular Ligament in Acquired Flat Foot Deformity and in the Operative Correction by Lateral Calcaneal Lengthening

Category:HindfootIntroduction/Purpose:Different factors are well known influencing the development of adult acquired flatfoot (AAF) deformity. So far less attention was paid to the lateral ligament complex. The idea that the anterior talofibular ligament (ATFL) probably influences AAF could be obvious concerning its anatomical course. Goal of this study is to assess the influence of ATFL on AAF and on operative AAF correction by lateral calcaneal.Methods:We reviewed all patients that undergone lateral calcaneal lengthening in AAF from 01/01/2008 to 07/31/2018 in our clinic. Patients were grouped in patients with intact ATFL and in those with injured ligament. Two independent readers performed assessment of common radiographic flatfoot parameters in preoperative and postoperative radiographs.Results:Statistical significant difference between two groups could be observed for preoperative talonavicular uncoverage angle (p=0.018) and talocalcaneal angle (p=0.032), with more severe AAF in patients with injured ATFL. The other common radiographic parameters showed no significant difference, although a tendency to a more severe AAF could be observed within the group with damaged ATFL. No difference could be observed in surgical outcome or consistency after lateral calcaneal lengthening between two groups.Conclusion:ATFL seems to take impact in AAF concerning talonavicular uncoverage angle and talocalcaneal angle. In patients undergoing lateral calcaneal lengthening the integrity of the ligament seems not to influence the degree of correction or the consistency of the postoperative result.

Severe Flexible Pes Planovalgus Deformity Correction Using Trabecular Metallic Wedges.

Lateral column lengthening and plantarflexion dorsal opening wedge osteotomy of the medial cuneiform are 2 commonly used procedures to address the deformity seen in severe flexible pes planovalgus deformity. Traditionally, iliac crest allograft or autograft has been used to fill the osteotomy sites. Porous metallic wedges can be used as an alternative to avoid the concerns associated with both autograft and allograft. We performed a retrospective review of patients who had corrective osteotomies utilizing metallic wedges to address flexible pes planovalgus with at least 2 years of follow-up data. Preoperative radiographic measurements (anteroposterior [AP] and talo-first metatarsal angle, calcaneal pitch, talocalcaneal angle, and talonavicular uncoverage angle) and functional scores (visual analog scale [VAS] pain, Foot and Ankle Ability Measure [FAAM] Activities of Daily Living [ADL], FAAM Sports) were compared to postoperative radiographic measurements and functional scores. There were statistically significant improvements in all radiographic parameters and functional scores. Two nonunions were seen, one of which healed with revision surgery while the other was asymptomatic. At the time of last radiographic follow-up, there were no recurrences of deformity or collapse. Porous metallic wedges offer an attractive alternative to autograft and/or allograft in the setting of corrective osteotomies for severe flexible pes planovalgus. Patients who underwent corrective osteotomies using these wedges demonstrated reliable, effective, and stable radiographic correction as well as significant improvements in function and pain. Level IV, case series.

Instability of the First Ray and Hallux Valgus in Patients with Adult Acquired Flatfoot Deformity (AAFD)

Category: Bunion Introduction/Purpose: Longitudinal arch collapse and first ray instability represent landmarks for adult acquired flatfoot deformity (AAFD), and have been linked to the development and progression of hallux valgus (HV). Radiographic evaluation of first ray instability is usually marked by increased angulation between the first and second metatarsals. The 1-2 intermetatarsal angle (IMA) is also an important aspect in the staging of HV deformity. Weightbearing CT imaging (WBCT) provides three-dimensional evaluation of dynamic deformities such as AAFD and HV. The purpose of this study was to assess the correlation between hallux valgus severity and foot collapse indicators using WBCT measurements, in patients with AAFD. We hypothesized that a flattening of the longitudinal arch, increased hindfoot valgus and forefoot abduction would correlate with greater IMA and HV angles. Methods: In this retrospective comparative study, 108 patients with stage II AAFD, 36 men and 72 women, with a mean age of 54.4 (range, 20-78) years, had their WBCTs evaluated by 2 blinded and independent board-certified foot and ankle orthopedic surgeons. The readers assessed multiple variables related to the severity of the hallux valgus and flatfoot deformities including: 1-2 intermetarsal angle, hallux valgus angle, talocalcaneal angle in the axial plane, talus-first metatarsal angle in the axial and sagittal planes, hindfoot alignment angle, hindfoot moment arm, navicular- and medial cuneiform-floor distance and the talonavicular uncoverage angle. Intra- and interobserver reliability were calculated by Pearson or Spearman’s correlation and intraclass correlation coefficient, respectively. A multiple regression analysis was used to evaluate the correlation between the variables indicative of AAFD and the severity of HV. P-values less than 0.05 were considered significant. Results: The intra- and interobserver reliability ranged from (0.65-0.99). Means and standard deviations for IM and HV angles were 11.3°±3.7° and 17.6°±13.4°, respectively. These angles significantly correlated with each other (p&lt;0.0001). Most of the AAFD measurements evaluated were significantly associated with either increased IM or HV angles. IM angle correlated with increased talocalcaneal (26.0°±10.3°, p&lt;0.0001), talus-first metatarsal (19.0°±13.6°, p=0.0001), and hindfoot alignment angles (22.3°±12.9°, p= 0.0049). HV angle correlated with medial cuneiform-floor distance (15.1mm±5.5 mm, p=0.0183), talus-first metatarsal angle in the axial plane (p=0.0004) and sagittal plane (15.7°±8.8°, p=0.0351), talonavicular uncoverage angle (17.8°±13.9°, p=0.0035). Hindfoot moment arm and navicular-floor distance were the only AAFD measurements that did not correlate with IM or HV angles. Conclusion: To the best of our knowledge this is the first study to confirm the association between AAFD, first ray instability and hallux valgus deformity using WBCT images. Our study results demonstrated that stage II flatfoot patients indeed have increased intermetatarsal and hallux valgus angles. Measurements traditionally used for staging the severity of AAFD showed significant positive correlation with increased IM or HV angles. Even though cause and effect cannot be determined with certainty, foot and ankle surgeons should consider these findings during evaluation and surgical planning of patients with AAFD.

Weightbearing CT and MRI findings of Stage II Flatfoot Deformity

Category: Hindfoot Introduction/Purpose: Adult acquired flatfoot deformity (AAFD) is characterized by concurrent bony deformities, tendinous and ligamentous insufficiencies. Weightbearing CT (WBCT) is a new imaging technique that allows excellent evaluation of the relative three-dimensional positioning of the tarsal bones in dynamic deformities such as AAFD. MRI, on the other hand, provides an accurate evaluation of soft tissue integrity in the unloaded foot. The objective of this study was to evaluate the correlation between bone deformity and soft tissue insufficiency in patients with stage II AAFD, using WBCT and MR images. We hypothesized that a significant correlation would be found between WBCT measurements of increased longitudinal arch collapse, hindfoot valgus, peritalar subluxation and forefoot abduction, with MRI findings demonstrating degree of involvement of ligaments and posterior tibial tendon (PTT). Methods: This retrospective comparative study included 55 patients (56 feet) with stage II AAFD, 20 men and 35 women, mean age of 52.5 (range, 20 to 78) years. Multiple WBCT and MRI variables related to the severity of the deformity were evaluated by four blinded and independent readers (two radiologists and two foot and ankle surgeons), including: arch collapse (navicular-floor distance and forefoot arch angle), hindfoot alignment angle (HAA), forefoot abduction (talonavicular uncoverage angle), subtalar joint subluxation, sinus tarsi and subfibular impingement, and soft tissue insufficiency (posterior tibial tendon, spring and talocalcaneal ligaments). Tendinous and ligamentous involvement on MRI were graded from zero (normal) to four (complete tear). Intra- and interobserver reliabilities were assessed by Pearson/Spearman’s and intraclass correlation coefficient, respectively. A multiple regression analysis was used to evaluate the relationship between bone alignment (WBCT variables) and soft tissue injury (MRI variables). P-values of less than 0.05 were considered significant. Results: We found overall good to excellent intra (range, 0.83-0.99) and interobserver reliability (range, 0.71-0.97) for WBCT measurements and MRI readings. Spring ligament superomedial component involvement was the only finding to correlate with medial column collapse and decreased navicular-floor distance (p=0.03). Superomedial spring ligament and PTT degeneration were also significantly correlated with increased HAA (p&lt;0.01). Involvement of the talocalcaneal interosseous ligament significantly correlated with increased forefoot abduction as measured by the talonavicular uncoverage angle. Spring ligament degeneration, of both superomedial and inferior components, and talocalcaneal interosseous ligaments significantly correlated to subtalar joint subluxation (p&lt;0.001). Involvement of the talocalcaneal interosseous ligament was the only one to significantly correlate to the presence of subfibular impingement (p=0.02). Degeneration of the PTT was significantly associated with sinus tarsi impingement (p=0.04). Conclusion: This study is the first to evaluate correlation between bone, tendinous and ligamentous involvement in AAFD patients, using WBCT and MR images. Our results demonstrated that progressive bone deformity in WBCT is significantly correlated to MRI involvement of the PTT and other important restraints such as the spring and talocalcaneal ligaments. The implications are that WBCT can predict ligamentous injuries and that MRI can predict dynamic bone deformity in AAFD patients. Furthermore, the correlation of bone and soft tissue involvement could impact surgical planning of flatfoot patients, decreasing thresholds for additional soft tissue procedures such as a spring ligament reconstruction.

Correction of Severe Flexible Pes Planovalgus Deformity Using Trabecular Metallic Wedges

Category: Hindfoot, Midfoot/Forefoot Introduction/Purpose: Lateral column lengthening and a medial cuneiform plantarflexion (Cotton) osteotomy are procedures commonly used in the treatment of symptomatic flexible pes planovalgus. Traditionally, structural autograft or allograft have been used for both osteotomies. While union rates for both types of graft have been shown to be comparably high, the use of allograft or autograft each come with their own set of inherent risks and/or potential complications. A trabecular titanium wedge implant provides an attractive alternative that avoids the concerns associated with autograft and allograft use, and has previously been shown in the literature to demonstrate similar union rates. The purpose of this study was to retrospectively review the radiographic outcomes of corrective osteotomies utilizing trabecular metal wedges to address severe flexible pes planovalgus deformity. Methods: 115 feet in 109 patients who were treated with corrective osteotomies using a trabecular titanium wedges performed by one surgeon were retrospectively reviewed. All patients had symptomatic flexible pes planovalgus, mostly secondary to stage IIB posterior tibialis tendon dysfunction. Other diagnoses included pes planovalgus secondary to the adolescent idiopathic flexible subtype, traumatic posterior tibialis tendon rupture, coalition, or an accessory navicular. Preoperative radiographic parameters assessing severity of deformity were recorded and compared to the postoperative measurements taken at the time of most recent follow up visit to assess for correction. The radiographic measurements included the (1) AP talo-1st metatarsal angle (2) Lateral talo-1st metatarsal angle (3) Calcaneal pitch (4) Lateral talo-calcaneal angle and (5) Talonavicular uncoverage angle. All angles were measured off standard weight-bearing radiographs by one author using our institution’s picture archiving and communication system (PACS) software. All complications were also recorded. Results: At an average follow up time of 40 weeks, there were statistically significant corrective changes in the AP-talo-1st metatarsal angle (-12.56), lateral talo-1st metatarsal angle (+14.15), calcaneal pitch (+5.23), lateral talo-calcaneal angle (-3.87) and talonavicular uncoverage angle (-17.76). There were 3 nonunions (2.6%) confirmed by CT, 2 of which were eventually revised. There were a total of 9 complications (7.8%). Other than the nonunion revisions, none of these complications required a return to the operating room. There were no cases of collapse or loss of correction at the time of followup, as compared to the initial post-operative radiographs. Conclusion: In our study population corrective osteotomies using a trabecular titanium wedge was effective in improving radiographic parameters associated with flexible pes planovalgus deformity. The nonunion and overall complication rates using a trabecular titanium wedge were shown to be comparable or superior to what has previously been reported in the literature using allograft or autograft.